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t ` APPLICATION FOR PERMIT + SAN JOAQUiN LOCAL HEALTFDISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. I I,C Telephone (209) 466-6781 DATE ISSUED jp PERMIT EXPIRES 1 YEAR FROM 0.4TE "ISSUED (Complete in Triplicate) Application is,-.hereby made to the San Joaquin Local Health District for a permit tb construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules" and Regulations of the San Joaquin Local Health District, i Job Address . - ee� Owner's Name Address iT✓ Phone Contractor's Name_ Li nse No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U O pG "DISTANCE TO NEAREST:-'SEPTIC 'TANK SEWER LINES i DISPOSAL FLD. PROP. LINE (A U 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I strial E Ope Bottom Manteca Dia. of Well Excavation Domestic/Private ravel Pack Tracy Dia. of Well Casing Public Other Del to Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal— f Geophysical *Kt rd��s' ( Y1Type of Grout LJ Other �f Surface Seal Installed by Repair Work Done ❑ Type of Pump _ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: ! Number of bedrooms Lot size k Character-of soil to a depth of"3A-feet:-" Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line" DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Fj Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner as to become subject to workman'; compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which, this permit is issued, 1 shall employ persons subject to wor an's compensation laws of California." The applican ust call for 11 require inspect' S. m 1 e drawin on rev e a si e. Signed X Date: 9-121—93 h FO SE ON Application Accepted by Area g2/ Stk 466-67B1 Additional Comments: _ Lodi "-369-3621 t Pit or Grout Inspection Dateanteca 823-7104 j Final Inspection by Date ❑ Tracy 836-6385 Applicant -.Return all copie to: Envir mental ea th Permit/ServiP. Hazces 1601 lton Ave., P.O. Box 2009, Stk., CA 95201 rFEE BASE. AMOUNT . DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. FO �p 91 ` _ d —2- EH yEH 13-24 REV. 10/82 10/82 500 14-26